Emergency department (ED) overcrowding can not only increase patient morbidity and mortality but also put providers themselves at risk.
The use of standard diagnostic pathways in the ED and continued care at home can reduce ED overcrowding.
Providers should identify patients who are more likely to visit the ED for non-emergent reasons and counsel them regarding other options for urgent care.
Overcrowding in the emergency department (ED) is nothing new. It was first recognized in the 1980s, and things have only worsened since then.
Studies have shown that crowding in the ED is related to patient discomfort, treatment delays, adverse patient outcomes, decreased patient privacy, violence toward staff, higher clinician/nurse turnover, and increased burnout, according to a Yale News article published by Yale News.
But what factors are contributing to this overcrowding problem, and how can clinicians help address them?
The boarding problem
“Boarding” refers to holding admitted patients in the ED while they wait for an inpatient bed. The Joint Commission warned that boarding is a patient safety risk and should not extend past 4 hours.
Authors of research published by JAMA Network Open noted that boarding is also associated with decreased patient privacy, medical errors, and higher death rates. It indicates that hospital resources are overwhelmed, and this usually happens when hospital occupancy is greater than 85%–90%.
The Yale researchers publishing in the JAMA Network Open article surveyed 1,769 hospitals in December 2021 to study boarding rates during the COVID-19 pandemic. They found that occupancy rates and boarding time exhibited a “threshold” relationship. Specifically, when occupancy was greater than 85%, boarding exceeded the Joint Commission’s 4-hour standard in 88.9% of the months analyzed.
During the months studied, the median ED boarding time was 6.58 hours compared with 2.42 hours in other months. In January 2020, the median boarding time was 2.00 hours, but it rose to 3.42 hours in December 2021. Median hospital occupancy was highest (69.6%) in January 2020 and was 65.8% in December 2021.
Left without being seen
When EDs are overcrowded and wait times are long, patients often leave without being seen.
Walking out before receiving medical evaluation may lead to delayed care for acute conditions.
Leaving before being seen has been found to occur despite initiatives to link ED patients at increased risk (such as those experiencing opioid use disorder) to care. The left-without-being-seen (LWBS) phenomenon disproportionately impacts minority populations.
The same researchers who studied boarding rates in the ER published a complementary study in JAMA Network Open on LWBS rates in the same hospitals.
The investigators found that hospital LWBS rates approximately doubled from 1.1% in 2017 to 2.1% by the end of 2021. Among the worst-performing hospitals (ie, 95th percentile), the LBWS rate was 10% by the end of 2021 versus 4.3% in 2017. LWBS incidents were more common in hospitals that served low-income populations.
“Historically, LWBS was viewed as an ED management problem rather than a hospital- or systems-level issue,” the authors wrote. “Thus, most solutions to date have relied on intradepartmental operational fixes to mitigate ED crowding; for example, doctor-in-triage or split-flow models offer more rapid medical screening evaluations, effectively bypassing traditional triage processes.”
“These processes promote rapid but limited physician evaluations, often in the waiting room,” they added. “Amid the current crisis, these ED-focused operational efforts may be inadequate to stem this growing problem.”
What clinicians can do
One way to decrease ED wait times is to use standardized diagnostic pathways reflecting overt clinical presentations. These pathways may also decrease the chance of errors and rates of hospitalization, as well as decrease the frequency of adverse events and death, according to research published by the Journal of Personalized Medicine.
Another way to help decrease ED overcrowding is to make use of situations where the patient has adequate home care. Patients who don’t need to be hospitalized can continue their care at home after being diagnosed, stabilized, and initially treated in the ED.
"The possibility of being able to continue treatment at home offers countless advantages to different populations of patients, especially the elderly, who find themselves in a familiar and comfortable environment, structured according to their needs, being able to continue care in a psychologically more congenial way."
— Savioli, et al., Journal of Personalized Medicine
It's imperative that healthcare professionals (HCPs) identify frequent utilizers of the ED and determine the reasons for their multiple visits. Contributing factors could include poorly controlled medical or psychiatric illness, unemployment, or housing insecurity, according to the Transforming Clinical Practice Initiative (TCPI).
Collaborating with local EDs may help determine which patients have used the ED. Clinicians can then follow up with these patients within a few days after the ED visit. When contacting them, it’s important to answer their questions and review any medication prescribed. For consistency and thoroughness in how information is gathered on a patient’s recent ED visit, the TCPI advised using a checklist developed specifically for this purpose.
Keep in mind that the most common reasons patients visit the ED with non-emergency presentations have to do with the lack of a PCP relationship, as well as a paucity of after-hours services and difficulty getting a timely appointment with a physician.
To help remedy this issue, practices can provide extended evening and weekend hours of operation and offer access to 24/7 advice from an HCP for urgent matters. When a patient does present with an urgent concern during regular work hours, however, their care should be prioritized.
Other options include the use of telehealth or face-to-face visits with someone other than the physician, such as advanced practice providers who are qualified to manage urgent-care issues.
Above all, patients should be informed—and frequently reminded—that these options exist, and they should be advised to use them instead of the ED when appropriate.
What this means for you
ED overcrowding is a problem that impacts various facets of healthcare including patient morbidity and mortality. Often, unwarranted ED visits arise from access issues. Practices that accommodate the needs of their patient population with extended hours and telehealth options can help close the care gaps and reduce patients' use of the ED for non-urgent matters.